History of preventive and social medicine in India.HP Thakur, DD Pandit, P Subramanian
Department of Preventive and Social Medicine, Seth G. S. Medical College, K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
Keywords: History of Medicine, 18th Cent., History of Medicine, 19th Cent., History of Medicine, 20th Cent., India, Preventive Medicine, history,Social Medicine, history,
Preventive and Social Medicine (PSM) is relatively a new branch of medicine. It is often considered synonymous with Community Medicine, Public Health, and Community Health in India. All these share common ground, i.e. prevention of disease and promotion of health. In short, PSM provides comprehensive health services ranging from preventive, promotive, curative to rehabilitative services. The importance of the speciality of PSM has been very well recognised and emphasized repeatedly from grass root to international levels, not only in health sector but in other related sectors too. Whereas clinical specialities look after individual patient, PSM has to think and act in terms of whole community. The scope of medicine has expanded during the last few decades to include not only health problems of individuals, but those of communities as well. If we want to achieve Health For All, Community Medicine will definitely be the key factor during the next millennium.
The industrial revolution of the 18th century while bringing affluence also brought new problems - slums, accumulation of refuse and human excreta, overcrowding and a variety of social problems. Frequent outbreaks of cholera added to the woes Chadwick’s report on ‘The Sanitary Conditions of Labouring Population (1842)’ focussed the attention of the people and Government on the urgent need to improve public health. Filth and garbage were recognised as man’s greatest enemies and it lead to great sanitary awakening bringing Public Health Act of 1848 in England, in acceptance of the principle that the state is responsible for the health of the people. The act was made more comprehensive in 1875 when Public Health Act 1875 was enacted. The public health movement in USA followed closely the English pattern. The organised professional body, American Public Health Association was formed in 1872. The Indian Public Health Association was formed in 1958.
Public Health is defined as the process of mobilising local, state, national and international resources to solve the major health problems affecting communities and to achieve Health For All by 2000 AD.
While Public Health made rapid strides in the western world, its progress has been slow in the developing countries such as India where the main health problems continue to be those faced by the western world 100 years ago. The establishment of the World Health Organisation (WHO) providing a Health Charter for all people provided a great fillip to the public health movement in these countries.
Many different disciplines contributed to the growth of Public Health; physicians diagnosed diseases; sanitary engineers built water and sewerage systems; epidemiologists traced the sources of disease outbreaks and their modes of transmission; vital statisticians provided quantitative measures of births and deaths; lawyers wrote sanitary codes and regulations; public health nurses provided care and advice to the sick in their home; sanitary inspectors visited factories and markets to enforce compliance with public health ordinances; and administrators tried to organise everyone within the limits of the health departments budgets. Public Health thus involved Economics, Sociology, Psychology, Law, Statistics, and Engineering as well as biological and clinical sciences. Soon another important and emerging branch of medicine i.e., Microbiology became an integral part of Public Health. Public Health during the 19th Century was around sanitary regulations and the same underwent changes.
Preventive Medicine developed as a branch of medicine distinct from Public Health. By definition, preventive medicine is applied to ‘healthy’ people, customarily by actions affecting large numbers or populations. Its primary objective is prevention of disease and promotion of health. It got a firm foundation only after the discovery of causative agents of diseases and the establishment of the germ theory of disease. The development of laboratory methods for the early detection of disease was a further advance.
Social Medicine has varying meanings attached to it. By derivation, it is the study of man as a social being in his total environment. It may be identified with care of patients, prevention of disease, administration of medical services; indeed with almost any subject in the extensive field of health and welfare. In short, social medicine is not a new branch of medicine but rather a new orientation of medicine to the changing needs of man and society.
Community Medicine has been defined as that speciality which deals with populations…. and comprises those doctors who try to measure the needs of the population, both sick and well, who plan and administer services to meet those needs, and those who are engaged in research and teaching in the field.
Decades old concept of health care approach has experienced a dramatic change. Today health is not merely an absence of disease; it is related to quality of life instead. Health is considered a means of productivity. Thus health development is essential to socio-economic development as a whole. Since health is an integral part of development, all sectors of society have an effect on health. Scope of medicine has extended from individual to community. Study of health and disease in population is replacing study of disease in man. Germ theory of disease gave place to newer concepts - multi-factorial causation. Social and behavioural aspects of the disease have been accorded a new priority. Contemporary medicine is no longer solely an art and science for the diagnosis and treatment of diseases. It is also the science for the prevention of disease and promotion of health. Today technical sophistication of modern medicine is not an answer to everyday common ailments of the vast poor in the country. Appropriate technology and cheaper interventions like Oral Rehydration Solution (ORS), immunisation, etc are increasingly being applied as life saving measures and for disease prevention in community health care. Physicians’ role is no longer confined to diagnosing and treating those who come to the clinic. He is also responsible for those who need his service but can not come to the clinic. Health of the people is not only the concern of health care providers. It is the responsibility of the community also to identify and solve their own health problems through their active participation.
All these changes in concept and ideas of health and health care system are embodied in community health care. The spate of new ideas and concepts, for example, increasing importance given to social justice and equity, recognition of crucial role of community participation called for the new approaches to make medicine in the service of humanity more effective.
Alma-Ata declaration in 1978 specified that Primary Health Care approach was the way of achieving the goal of Health For All by 2000 AD. Primary Health Care approach stressed that “essential health care should be made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and the country can afford”.
The Public Health administration in India actually started in 1869 with the appointment of a Sanitary Commission. The first Municipal Act was passed in 1884 in Bengal. But in the Indian context J. P. Grant had visualised in 1939 that foreign models could not be suited for First Doctor Intervention or for Primary Health Care. His recommendations were also incorporated in Bhore Committee Report 1946, for building Community Physicians. The Bhore Committee’s Report laid the foundation of modern public health care in India.
On the recommendations of Medical Education Conference in 1955, departments of Preventive and Social Medicine were established in Medical colleges all over the country. The experimental learning of our predecessors and Gurus provided the foundation and led to growth and expansion of the frontiers of the subject of Community Medicine. It has today evolved as a field of learning that contributes immensely to the progress and development of societies, more significantly in developing nations like India. The professionals of Community Medicine have a major responsibility to shoulder i.e., to work for the health and well being of the people of India and contribute to education and production of basic doctors, well versed with handling community health problems. The objective of medical education is to produce a basic doctor who is competent to give comprehensive health care to individual, family and community. We need to bring about many changes, reforms in current medical education for achieving the desired objective.
These departments have teaching / training, service and research components. But initially more emphasis was placed on teaching / training aspect. Beyond 1975, faculty members of Community Medicine were enriched with the field experiences in training, monitoring and evaluation with active participation in various National Programmes like ICDS (Integrated Child Development Scheme), EPI (Expanded Program on Immunisation), UIP (Universal Immunisation Program), CSSM (Child Survival and Safe Motherhood programme), NACP (National AIDS Control Program), RCH (Reproductive and Child Health programme) and have shared their experiences with the District / State / National Health Programme managers and also translated their experiences in Undergraduate and Postgraduate training and teaching. There are variations in teaching / training in Preventive and Social Medicine in different states of India which reflects the cultural diversity and varying needs of the local community. The research component has been a very poorly developed component of PSM so far mainly because of scarcity of funds.
Medical colleges have the primary function of imparting undergraduate medical education. These colleges form the majority of institutions in India, which provide professional postgraduate qualification in Public Health. A school of public health like All India Institute of Hygiene and Public Health, Calcutta, especially established for the purpose without the responsibility of undergraduate medical education is an exception.
It is noted that many medical colleges are unable to have good community-oriented, field-based programmes for demonstration and participatory education of the undergraduates. Medical colleges, by and large, remain isolated from health care system and play very limited role in public health services. However, desirable and positive changes through various approaches are taking place in the medical education system all over the world and in our country to enable it to stand upto the expectations of the country in the context of its overall social-economic-health development process e.g., by reorientation of curriculum, by community-based integrated teaching or by making medical colleges assume direct responsibility in providing health care, etc.
The Government of India launched the Re-orientation of Medical Education scheme in the year 1977. The scheme aims at involving medical colleges directly in the health care delivery system by accepting total responsibility for promotive, preventive and curative health care of at least 3 Community Development Blocks in the first instance, ultimately extending to the whole district. The progress of the Scheme has been extremely slow in most colleges. There is hardly any impact on orienting medical students towards rural health care, which was its primary aim. Medical graduates from most medical colleges still pass out with the same pattern of education, which was present earlier, with more focus on curative medicine and urban oriented approach. The health care system in India including medical education, health care services etc. as such, and not only Preventive and Social Medicine departments can be held responsible for this.
In the words of ex-Director General of WHO Dr. Mahler. “Any thoughtful observer of medical schools will be troubled by the regularity with which the educational system of these schools is isolated from the health service systems of the countries concerned. In many countries these schools and faculties are, indeed, the proverbial ivory towers. They prepare their students for certain high, obscure, ill-defined and allegedly international ‘academic standards’ and for dimly perceived requirements of the twenty-first century, largely forgetting or even ignoring the pressing health needs of today’s and tomorrow’s society.”
In the field of Public Health & Preventive Medicine, tremendous changes have taken place, but greater changes can be anticipated in the coming decades. Ideas and policies cannot be static and planning must have enough flexibility to cope with the fast-changing world of science and technology, of industrialization and urbanization. It is obvious that new horizons and super-specialities are fast emerging in Preventive and Social Medicine, like Epidemiology, MCH (Maternal and Child Health), IEC (Information Education Communication), Health Management, Health Economics, Nutrition, Demography, Health System Research, Environmental Health, etc. Current developments in Information Technology will certainly alter the face of Preventive and Social Medicine in the coming future.
Regular self-assessment at an individual, institutional and at an association level is essential. Newer roles and responsibilities with ongoing ‘strength, weakness, oppportunities and threats’ analysis can be identified. It will definitely help in further image building of the speciality as well as improvement in health and overall development of the community.
There are many challenges in the field of Public Health. One of the challenges, which are successfully met, is “Eradication of Smallpox”. This is a wonderful achievement which all of us are proud of. Another disease, which is successfully eliminated, is Guineaworm disease. There were setbacks in some of the programmes like Malaria, Tuberculosis that made us rethink and remodify the strategies and re-implement these national health programmes. As we are able to control some diseases, there will be new emerging as well re-emerging diseases. This faculty has to be remain alert all the time and prepared for meeting the new challenges.
According to Charles Darwin, “It is not the strongest of the species that survive nor the most intelligent, but rather the one that is most responsive to change”. Preventive and Social Medicine has demonstrated it’s survival instinct so far and will definitely acclimatise itself to changes in the society and emerge a winner.